CALLS TO DIVERSIFY the nursing workforce have been so prevalent in past decades that the importance of diversity can almost seem assumed knowledge. Studies addressing workforce diversity gaps, the experiences and needs of underrepresented groups in nursing, and strategies to foster diversity are well documented in the nursing literature.1–6 Attention to workforce diversity has clearly resulted in progress,7,8 yet progress has not been realized equally among various underrepresented groups in nursing. Specifically, increasing gender diversity continues to be slow despite the long-standing recognition of the lack of men in nursing. Men accounted for 11.4% of the American registered nurses in 20189 and only 12.4% of students graduated from American schools of nursing with a bachelor's degree in 2018-2019.10 In comparison, women accounted for 35.7% of dentists, 40.3% of physicians and surgeons, and 63.4% of pharmacists in 2018.9 Furthermore, women earned nearly 50% of dentistry degrees in 2017,11 47% of medical degrees in 2018,12 and 62% of pharmacy degrees in 2018.13
Much of the literature on men in nursing has focused on historical accounts, personal narratives, expert opinions, descriptions of men's experiences, characteristics of men in nursing, barriers for men in nursing and nursing education, and comparisons between men and women in nursing.14,15 Relatively little published work has addressed the influencing factors and social structures that explain the persistent shortage of men in nursing. Most of the literature identifies patriarchy as the foundational and explanatory paradigm for gender issues in nursing and health care overall. Patriarchy, in this context, is seen as an oppressive social system that prescribes narrow gender norms, designed to ensure and sustain power hierarchies that benefit masculine men who conform to the prescriptions.16 In the history of job professionalization, this has meant creating “masculine” and “feminine” occupations and devaluing “feminized” work, such as caring for others.17 Syntheses of this literature describe how patriarchy has shaped the specific assumptions, perceptions, and experiences related to men in nursing, particularly when it comes to the type of nursing work men are seen as suited for (eg, high stress environments) and the type of care they should avoid (eg, personal care, therapeutic touch).14,18 While there is an intuitive and experiential knowledge of the harmful impacts of patriarchal norms to both men and women, it remains a challenge, however, to develop generalizable assessments of gendered professional cultures so that concrete measurable strategies toward improving equity may be envisioned.
Gender role conflict (GRC) offers an alternative approach to more directly understand the socially embedded contributing factors for the shortage of men in nursing, particularly in the areas of male recruitment and retention. This framework seeks to measure and describe the harmful effects gender norms have on a person's psychological well-being and decision-making. As a middle-range theory, GRC was first proposed by James O'Neil19 in the late 1970s and has been extensively studied and applied in men's studies and the social sciences. GRC has not been well explored in male nurses or nursing students to date, but it may offer a promising model for mitigating gender disparities within nursing. This promise was suggested in the current project where connections to GRC emerged in our analysis of qualitative interviews conducted as one part of a mixed-methods study about the experiences of male nursing students.
Statement of Significance
What is known or assumed to be true about this topic:
The need to diversify the nursing workforce is well recognized, yet despite progress toward diversification, gender diversity continues to lag far behind the successes realized by women in traditionally male-dominated health care professions. Men's experiences in nursing are well described in the literature, but little is known about the influencing factors and social structures that explain the persistent shortage of men in nursing. Gender role conflict (GRC), a middle-range theory researched extensively in the social sciences, is an effective model for operationalizing the broader theoretical assumptions of patriarchy in order to develop and test strategies that mitigate societal challenges associated with gender. The utility of GRC in addressing the lack of gender diversity in the nursing workforce is unexplored.
What this article adds:
We explored a diverse sample of male nursing students just starting their baccalaureate program to better understand any gendered influences experienced in deciding whether or not to pursue a nursing career. On the basis of the findings, we constructed a decision-making process model in which students considered gendered internal and external contrasting influences. The model supports and extends previous research on the career decision-making processes of male nurses. We then evaluated the findings for fit with assumptions of GRC. We determined that GRC is an appropriate model to examine phenomena related to men in nursing and can be used to develop meaningful strategies to improve gender diversity in nursing.
O'Neil19,20 defines GRC as a psychological state in which socialized gender roles have negative consequences for oneself and others. GRC occurs when rigid or sexist gender roles lead to restrictions, devaluations, or violations levied against one's self and/or others. O'Neil20 further defines restrictions as attempts to control one's behavior and those of others to conform to stereotypical and restrictive norms, consistent with the ideology of masculinity. Devaluations are negative critiques of self and others, resulting from occurrences of gender role nonconformity. Gender role violations are the most severe manifestation of GRC, resulting in harm to self and others. Such harm stems from emotional and physical pain and trauma due to restrictive gender role norms, resulting in destructive behaviors such as overwork, excessive stress, risk-taking, misogyny, homophobia, and even abuse and assault.19 As of 2017, well over 200 published domestic and international studies have examined GRC particularly in the disciplines of sociology and psychology. This body of research supports the introduction of therapeutic interventions for mitigating GRC and improving the psychosocial health of men and, by extension, society at large.19,21
Most studies measure GRC quantitatively and investigate correlations to relevant developmental, psychological, and social experiences. Criticisms of GRC research conducted to date highlight the lack of exploration of context in how GRC develops and manifests within and among individuals.22,23 These critiques have prompted O'Neil and his colleagues to propose additional GRC models inclusive of micro- and macro-societal contexts, including contexts related to employment and professional development, and issue calls for both qualitative and quantitative studies.19 Of interest, only one study was located that examined GRC in the experiences of male nurses. Hwang and Ja Kim24 found a significant negative correlation between GRC and job satisfaction and a positive correlation between GRC and intent to leave one's current nursing employment.
Although GRC-specific research in nursing is limited, literature syntheses report well-described challenges for men in nursing as they negotiate socially constructed perceptions of a feminized nursing profession with hegemonic and stereotypical masculinity norms, roles, and schemas.14,15,18,25,26 These challenges may contribute to negative outcomes such as low recruitment and retention of men in nursing. Importantly, these challenges along with men's published experiences and behaviors could be aligned with GRC constructs and outcomes as described by O'Neil.19 For example, studies from countries in which men were placed into nursing programs not in line with the men's preferred career choice report that many men display gender role restrictions, devaluations, and even violations.27–29
Since GRC has not been examined fully in nursing, but its claims find resonance in research on men in nursing, GRC became a sensitizing framework for the present study. At the same time, following the grounded theory methodology described later, we were mindful to allow meanings to be constructed freely from the data, further developing our understanding of GRC in the context of nursing and men's experiences in the field. According to Bowen, the use of sensitizing concepts to “lay the foundation for analysis of research data”30(p14) is congruent with grounded theory approaches, as long as those concepts are not “forced” on the data. Charmaz defined sensitizing concepts “points of departure from which to study the data.”31(p259) In the present study, the idea of GRC served a sensitizing concept, suggested by the existing literature that has documented the impact of (perceived) gender norms on the experiences of men who decide to become nurses. We were attuned to discussions of gender that emerged in the interviews without imposing GRC as an analytical frame.
Since gender diversification of the nursing workforce relies on the successful recruitment of men, the present study focused on men's considerations while deciding to pursue nursing as a career. Specifically, we wanted to learn more about (a) how do men decide to become nurses; and (b) how, if at all, were gender constructions present in men's discussions of their decisions to become nurses?
Study design and participants
An interpretive study design, congruent with constructivist grounded theory,32 was used to address the study's qualitative questions. This method was selected as a result of the congruence between the theory's roots in symbolic interactionism and the social constructions associated with understanding and doing gender.33 Furthermore, constructivist grounded theory recognizes the cocreation of knowledge from researcher and participant interaction32; 3 of us are male nurses and all are academics familiar with the literature base.
After receiving approval from the university's institutional review board, participants were drawn from 2 admission cohorts (September 2016 and January 2017) of prelicensure baccalaureate male nursing students enrolled in a multicampus nursing program in the United States who had responded to a survey used in the quantitative arm of the study. A total of 123 men responded to the survey, resulting in a response rate of 27.8% of all men admitted in the 2 cohorts from 20 individual campuses. Each respondent received an invitation via e-mail to participate in the qualitative arm of the study.
Data collection and analysis
Individual interviews were scheduled with participants upon receiving signed informed consent. Each coauthor conducted 3 to 5 separate interviews. We interviewed participants via telephone using a structured interview guide. Guiding questions explored the participants' processes and experiences while deciding to become nurses, responses and support from others upon learning of participants' decisions, and participants' perceptions about nursing's fit with personal and societal constructions of gender. Other questions touched on participants' work, family, and faith backgrounds, and how these may have impacted career decisions. We asked additional and follow-up questions, as needed.
Data analysis was congruent with methods of constructivist grounded theory.32 We conducted preliminary analyses of our own transcripts independently, constructing initial codes embedded within the narratives. Initial codes were then collapsed into focused codes that better captured the processes and actions evident in the data. We used NVivo 11 to organize codes and link them to textual support from the transcripts. We generally constructed codes as gerunds to better communicate analysis and actions, congruent with Charmaz's32 recommendations. We met after the first few interviews to review, discuss, and debate the various focused codes in order to discern areas of similarity, nuance, and difference. Subsequent interviews were conducted with additional participants, probing areas in need of clarification, while still seeking new information. Initial and focused coding continued, followed by additional discussions. Interviews continued until information became redundant and no new substantive focused codes were constructed, suggesting data saturation. Through a collaborative back-and-forth process, we refined the focused codes and used the strongest codes to construct categories and, ultimately, the overarching theoretical concept.
We employed measures to ensure qualitative rigor and support trustworthiness of the findings.34 The sample represented diversity in race/ethnicity, geographic location, age, and work experience. We double-checked transcripts from recorded interviews for accuracy. Constructed codes were aligned with supporting text and displayed for analysis in NVivo11. We engaged in constant comparisons within and among interviews and kept theoretical memos. Findings were developed collaboratively and sent to participants for a members' check. Finally, we reviewed findings in light of the literature as a means of triangulation.
A total of 18 interviews with 17 men were conducted. Participants hailed from 9 different campuses, spanning the country from New Jersey to California. Thirteen (76.5%) of the men identified as white, 15 (88.2%) as heterosexual, and 12 (70.6%) as single/never married. The mean age of the men was 26.5 years (SD = 5.7).
Analysis yielded one overarching concept, Men deciding to become nurses, as the explanatory decision-making process used by the men (see the Figure). The concept comprised 3 categories (Considering the decision; Making the decision; and Realizing the decision), which characterize the generally progressive, though overlapping, phases the men experienced from first entertaining the thought of a nursing career to postenrollment as a nursing student. Transitions between stages, and thus their duration, were marked by participants' own words (eg, “And then I decided to apply.”) rather than arbitrarily determined by the researchers.
Each of the 3 phases was impacted by sets of dialectical factors (contexts, experiences, beliefs, and relationships) comprising synthesized focused codes. The relative weight of these copresent, yet opposing, factors influenced the quality, speed, and experiential nature of each phase and overall forward progression through the decision-making process. Some factors had influence in more than 1 phase, indicative of their overall persistence. As such, certain factors may influence progression into more of a back-and-forth style of movement. For example, a person may have already made the decision to apply to nursing school but reconsider it while preparing the application essay and discussing with loved ones.
Considering the decision
The first phase, Considering the decision, is one in which participants described themselves as beginning to think of nursing as a viable career option, followed by information seeking and decision-making. Activities in this phase included gathering information and advice from people in one's life, accessing external career information resources, reflecting on personal preferences and characteristics, weighing the pros and cons of a career in nursing, and comparing nursing among other possible career alternatives. For some, this phase was relatively compressed; for others, this phase spanned a number of years. The placement of this phase within each man's growth and development journey also varied. Some men entered this phase during their teenage years, whereas others entered only after having other types of adult employment and/or military service. The men did not necessarily engage with these activities in a sequential or methodical manner. Instead, after nursing was first recognized as an option, the men engaged in activities concurrently in an integrative and exploratory manner.
Two sets of opposing factors were at play during this phase, some that facilitated the decision while others impeded it. One set, Facilitating the decision, comprised factors that encouraged men to view nursing favorably. Each man in the study experienced a unique subset of these factors, with each factor levying variable weights of influence that fluctuated over the phase's time span; yet, each factor was grossly evident within the sample as a whole. Factors did not work in an exclusive fashion; they occasionally worked synergistically, a pattern noted in all other sets of factors. For example, a number of men wanted careers in which they could help people, strengthened by personal experiences and engagement with positive male role models in their lives who themselves were helping others. One student from East Africa emphasized the importance of his birthplace and the values he learned there by observing his father:
Even in the hard days, I remember when I was a kid, I remember my father used to have the dinner or lunch, and he called everybody in the neighborhood and somebody who doesn't have the money to buy that ... during holidays, you buy sheep or goats or a cow and you know you slaughter it and eat it together as a family. So he always invites people who are there who doesn't have that money. So, those kinds of stuff. I grow up watching my father does all that helping people as much as he can.
Several men described their admiration for men they knew who worked as nurses, including male family members. One participant stated:
And my family have been supportive as well, they have actually known a couple of male nurses even from the '90s when I was growing up I knew a couple of male nurses so I think that has been interesting too.... My family knew a lot of nurses and they are all still working and happy with it so they viewed it as a good career and I think that has influenced how I viewed it too.
Several men also spoke about personal attributes they possessed that they believed were congruent with nursing values and practice. For example, one stated that he and others had observed how caring he was, another described his altruistic beliefs and dedication to service to others, while another felt “called to nursing” to help save lives. Others described themselves as compassionate and empathetic.
In contrast, Impeding the decision included factors that gave some of the men pause while considering nursing as a career choice. For example, all the men either acknowledged or confronted negative stereotypes and negative masculinity messages prevalent in society, particularly around gender roles and expectations (eg, male nurses are effeminate, homosexual, unable to land more prestigious careers). These may have influenced gender self-constructions early in the decision-making process. One man reflected on a question he considered, “You're a male. Well, why don't you be a doctor? You know. It's not that easy.” Another man with an initial and inaccurate understanding of nursing practice contemplated the suitability of nursing for himself:
And you are not doing this directly, making the clinical decisions. Like most of the time you are following orders from a doctor and you are carrying them out and you are using your eyes and ears and your clinical knowledge to provide feedback to the doctor and give your input.
Generally, the men dismissed negative stereotypes and messages outright during this phase or noted that they were not applicable to themselves. In total, the collective weight of these negative factors was minimal or quickly overcome, leading the men to the next phase in the process.
Making the decision
The second phase, Making the decision, covered the time from selecting nursing as a career choice to starting a formal nursing education program as an enrolled student. Activities that constituted this phase included reflecting on the decision, sharing the decision with others, encountering the responses of others upon hearing about the decision, and preparing oneself for nursing school. Similarly to the first phase, these activities occurred concurrently. The length of time spent in this phase, depth of engagement with phase activities, and specific experiences occurring within this phase similarly varied among the men. However, a collection of influencing factors, organized into 2 opposing sets, was evident: Validating the decision and Questioning the decision.
Factors within the Validating the decision group involved encountering the positive responses of others and engaging oneself in self-discovery activities that strengthen one's resolve to become a nurse. The overwhelming majority of men in the sample described enthusiastic support from family, friends, and coworkers. For example:
She's [significant other] always been very supportive of me and backed me up the entire time as well as my friends and my close friends and their moms and my parents as well have been very supportive through the entire thing and think it's a very great fit for me for who I am as a person.
Another participant stated, “Honestly I only receive full support from everyone I've come across.” Some men described mild teasing from male friends but noted that the teasing was light-hearted, was made in good fun, and was easily dismissed. Several men described ease with dismissing jokes and teasing due to their self-confidence and comfort with their own ideas about gender roles. Participants commented on the suitability of nursing for them personally and for men in general. Comments on personal suitability were often made even without direct questioning, suggesting that they were well aware that their career choice was socially unusual and needed explanation and/or affirmation.
A number of men used their time in this phase to learn more about nursing, take academic courses required prior to enrollment in nursing school, and avail themselves of employment and volunteer opportunities in health care. Several of the men worked as nursing assistants or medical technicians prior to entry into formal nursing courses. These activities, by and large, grew the men's interest in nursing and validated the correctness of their decisions. Some of these prenursing caring experiences were particularly influential. One participant working as a nursing assistant shared the following:
She happened to be on the dementia unit, but she was fully aware of her diagnosis. She kind of told me about her life and how she didn't really have anybody. So, when I came along she kind of let me know how important it was that I shared that time with her. After that I kind knew that was something I really wanted to do for the rest of my life.
Several men described a new appreciation for nursing, including nursing's use of teamwork and collaboration, nursing's deep and caring engagement with others, the complexity of nursing practice, and opportunities within nursing.
However, some of the responses participants received from others were more guarded and even negative, indicative of the set of factors for Questioning the decision. Less-than-positive responses stemmed from negative stereotypes about men in nursing, the nursing profession as a whole, and were suggested as nudging the men into conformity with traditional gender roles. Typically, these responses fell into 2 camps: on the one hand was the stigmatization of male nurses as gay, which ran as a persistent theme across interviews and across the different decision-making phases, and on the other hand was a view of nursing as somehow less appropriate than more male-dominated health care careers. For example:
But I think a lot of people were surprised that I was ... I don't know what people think it is about me but people always think that I'm going to, you know, “I can see you going to be a doctor or something like that.” And I don't know if that's because I'm a guy, you know what I mean? There's the stereotype of that. I mean I don't think people were disappointed but were surprised though that I decided to pursue [nursing] instead.
Responses of this nature, possibly combined with self-constructed notions of gender, fed into a number of apprehensions expressed by the men. Despite broad self-acceptance, some men described their beliefs that others, particularly female instructors, patients, and families, would be nonreceptive to their entry into nursing and their nursing care.
Like I said it is 2017 so I feel like it is changing a little bit but not so much from ... patients, especially labor and delivery and stuff like that where the nurses might be fine with me working with them, the doctors and whatever, but you are in the patient's room and there is a couple there and maybe the guy doesn't want me in there because he is just not comfortable with it for whatever reason.
Some men wondered whether their gender would make them more susceptible to bias or a more attractive target when, as one participant stated, “...nurses eat their young.” Two of the men were apprehensive of possible jealousy from their wives that they would be enrolled in a program dominated by female peers.
Thankfully there is one other young man who is in my [pre-requisite] classes so far and I am grateful for that because I feel like I can connect with him. He is somebody I can build a relationship [as a study partner] without it being or looking inappropriate, as a married guy. If you are a guy like me and you are texting a woman late at night, it can only seem bad....
My wife will give me push back because it is just the way it is that I am in a study group with three other girls, or if their boyfriends might have push back, you are studying with the older guy. (Interviewer: Is that something you've discussed with your wife, you know, there is going to be a lot of girls in this group?) We have talked about it a bit and I am sure I will talk about it more. It is one of those things where it is like I am not just trying to hang out with a bunch of girls, I have to study. And I think she is realizing that. It has taken some work, but you have got to study. You have to go to classes.
These guarded and negative responses gave some of the men reasons for pause and, possibly, a heightened sensitivity to what might lie ahead. Nonetheless, as with the previous phase, the men in the sample were more influenced by factors that strengthened their confidence in and commitment to their decisions to become a nurse. These men moved forward to the next phase.
Realizing the decision
The third phase in the process, Realizing the decision, began with enrollment into a nursing education program. Activities inherent in this phase included those familiar to all nursing students such as taking coursework, studying, negotiating competing time constraints, engaging in self-development, and stress management. At the same time, men juggled a set of factors related to gendered constructions organized again into 2 opposing sets—Strengthening and Threatening the commitment to nursing. Each set includes factors present in the previous 2 phases but evidenced in different contexts or building on existing understandings while rendering new insights.
Strengthening commitment to the decision included factors that built on prior validation of the decision and cemented one's perspective he has, indeed, made the correct career choice. A stronger decision commitment occurred as men revised or abandoned any prior misconceptions of nursing practice as they learned nursing knowledge, applied that knowledge to laboratory and clinical experiences, and built professional relationships. These factors support a greater resolve, or possibly resiliency, to overcome struggles they may encounter as a male nursing student.
Support from family and friends experienced prior to enrollment in nursing school continued, but, as some of the men noted, this support was operationalized as active assistance that allowed men to direct attention to their coursework and academic demands. For this, the men were grateful, but at the same time, they felt pressure to be successful. For example:
Well, right now my wife is not working, she is starting to work part time but thankfully we are having a lot of support from my parents and my in-laws, being very gracious to us and helping us with time and also some finances so I am able to do this. So as a student I feel the pressure to perform, to make them proud, I am really dedicating this to my wife and to my family who are helping me do this because otherwise I would never be able to make this work....
Other men expressed gratitude for financial support from benefit programs and other sources of financial aid essential to actualize their career aspirations. The men also described support coming from the academic institution, faculty, and student peers all of which engendered feelings of acceptance.
So far I love it, I honestly really do.... I visited many other programs and none of them really felt as inviting compared to going to XXX University and actually feeling like I belong there and them actually wanting me to come there and be successful.
The men continued to grapple with negative stereotypes about male nurses after admission to the nursing program, but these were easily dismissed and, in some cases, turned around. For example:
Well, my guy friends immediately started with the gay jokes which I half expected because of the stereotypes associated with it.... But then as I got started with the program, I would suddenly be asked, “Oh, my stomach's been hurting the past two days. What do you think I should do?” And I had a few other friends ask, “Oh, how do you like nursing? Because I'm thinking of going into it.” So, there was a pretty big shift when they saw that their jokes weren't getting to me and I was actually passionate about wanting to do it and happy at work.
Of particular note, as men engaged in their nursing coursework, a number of the men began to deepen their understanding of the reality and depth of current nursing practice. Some men stated they were surprised at the amount of science used in nursing; others commented on a greater appreciation of caring and relationships nurses have with those they serve. When describing their understanding of the demands of nursing, some men referenced, unprompted, their own self-constructions of gender that might possibly position them well for a successful nursing career. For example:
It [nursing] is problem-solving at its finest. And this is an area that typically men gravitate towards, solving problems and fixing things, and I think that is why more and more men are becoming nurses, because of their natural inclination to fix things and a good career. They are both available in nursing.
Several participants described positive career attributes of nursing such as career stability, career mobility, and a salary that appealed to them and would appeal to other men as well. On the contrary, some self-constructions of gender may have exerted a negative effect and thus are included in the opposing group of factors, Threatening the commitment to the decision. At worst, these self-constructions could convince men that nursing, after all, is incongruent with who they are and their preferred types of career; however, this was not evident among the men interviewed. At best these self-constructions may impose artificial limits for men relative to the areas of nursing one pursues and may serve to limit men's exploration of the fulfilling attributes possible in other nursing specialties and roles they perceive as less masculine. Such limits pose a threat to men's commitment to their decision if gender-affirming specialties and roles are not readily within their grasp. Furthermore, negative self-constructions may damage relations with female colleagues, who may perceive these self-constructions as perpetuating the harm of patriarchy. Interestingly, some negative constructions of gender were reinforced by others, including female nurses whom the men knew.
I've been told that men just are the higher-ups rather than working the floor at all times, taking charge, the manager or even beyond that, because from my understanding ... [men] are pushed into those ranks whether you want to be or not.
Adding to the threat were descriptions of gender bias levied at the men, although such occurrences were quite the exception in the sample. A few men described rare instances of being shunned by female classmates. Several men presently working as health care assistants described having their care rejected by female patients. There was a recognition that such rejections would be a reality for them as nurses, though it was not clear whether such recognition influenced the men's developing preferences for the areas of nursing they hoped to pursue.
Most concerning, however, were descriptions of faculty bias, as reported by 2 of the men. The first description came from a student whose experiences were so negative that he left his original nursing program. He stated that multiple faculty members at his prior school believed that men lacked empathy and compassion and therefore did not belong in nursing. A second student described an encounter more fully.
I was questioned by one of my professors after class.... I was doing some Internet searches on my computer while [she was speaking with another instructor] because I couldn't follow along with what they were saying, and other students had their laptops open.... She says, “You know I have a higher expectation of my male students to pay attention.” And I said, “Well why is there an expectation of male students? Wouldn't you expect all your students to be that way?”...And she's like, “Well I just have a higher expectation of you guys because you guys need to work twice as hard as a female student.” And I didn't understand why. I still don't understand why. I don't understand why that comment was made.... I'm confused on that. And she wouldn't clarify. She just said, “It is what it is when you get in this field.”
Finally, struggles with time management pose a threat to decision commitment. Both female and male nursing students negotiate competing demands on their time from work, school, and family,18 and none of the men interviewed suggested that their time struggles were any greater than those of their female classmates. However, constructions of gender were relevant to this factor based on comments made by some of the men with spouses. These men described a traditional male role obligation to be a breadwinner and good provider for their families which they believed they could not fulfill as full-time students. A few men described feelings of damaged pride and “...letting my family down” but acknowledged that the short-term pain of their time in nursing school was worth the long-term potential of a nursing career.
A model for men's decision-making
The model constructed from the data analysis, Men deciding to become nurses, explains the decision-making process men make in choosing to embark on a nursing career. To better support men's recruitment and retention into nursing, it is important to understand that this decision-making is not impulsive, but rather complex, dynamic, and ongoing, influenced by multiple factors at several stages. The process is structured into 3 overlapping phases, with each phase influenced by sets of opposing factors. Participants considered the balance of these factors, as well as the relative importance in each participant's specific context, in making their decisions to move forward in their pursuit of a nursing career. This is unsurprising since the men interviewed were all located within the third phase, Realizing the decision. It is reasonable to believe that negative factors that carry great importance and influence for men might halt or regress forward movement or even prompt men to abandon nursing altogether. Exploration of such decisions would be necessary to further understand the interplay of opposing factors. Future research should, therefore, focus on sampling from men who pursued and, consequently, left nursing.
The factors described by men in the current project are congruent with those identified in multiple previous studies exploring the experiences of men in nursing. Negative factors, for example, included pervasive stereotypes that most male nurses are gay,26,35–38 that men should pursue careers more congruent with masculinity norms,26,39,40 apprehensions about acceptability as men providing intimate care to patients,36,41–45 and anti-male bias and discrimination from nursing faculty and nurses.38,44,46–49 Notably absent in the current findings were other published negative barriers such as feminine imagery, isolation, and feminist pedagogy. However, the finding that some men encountered or were concerned about jealously from female partners is unique and presumably unrecognized by a profession that is predominately female and heterosexual.
Similarly, positive factors described by the men mirrored those from previous studies. Men were drawn to the positive attributes of a nursing career,29,50–52 were attracted to nursing out of altruism and a desire to help others,26,50,53 received affirmation and support from family and friends,29,51,53,54 and were positively influenced by male nurses, male role models, and personal experiences in health care and caring for others.26,53,55 Abundantly evident among the sample was men's ability to dismiss negative comments or stereotypes about men in nursing and their determination in not allowing such negativity dissuade them from their career path. This suggests a confidence with their own constructions of gender roles and a resiliency to negativity. A similar finding was noted by Yang et al56 among Taiwanese male nursing students.
The congruence of the findings with previous studies lends credibility to the model. Negative factors from published studies not realized with the present findings not only may be indicative of the individual experiences of the men in the sample but may also be due to changing gendered perspectives in certain sociocultural contexts related to the fit of nursing for men. For example, studies from Iran, Turkey, and China suggest a sociocultural context more in line with hegemonic male gender role schemas and yield some negative factors not found in the current study.27–29,57 Increased exposure of men in nursing and the larger social critique of patriarchal structures and traditional masculinity may be relevant here; further exploration is warranted. The model also bears striking similarities to the one earlier proposed by Larocco,51 which comprises similar sets of influencing factors. Larocco's51 sample, however, included male nurses in practice for several decades who relied on memories of early decisions and influences from the distant past. The present model represents more contemporaneous perspectives and, additionally, provides a more explicit depiction of opposing sources of influence, which aligns with and accounts for the individual experiences of men as they decide to become nurses.
The present model better informs career counselors and nursing programs in designing recruitment and early retention actions than have past models. The present model also increases awareness of the variable factors that may exert opposing influences on men's decision-making. While many of the negative factors are deeply embedded in social structures beyond the ability of individual counselors and nursing programs to substantively impact (a notable exception being any outward anti-male bias within academic programs); interventional attention to positive factors can do much to tip the balance. For example, since many of the men describe exposure to other nurses as persuasive, current nursing students and nurses could be encouraged to reach out to the men in their lives to consider a nursing career. Since many of the men described caring experiences as persuasive, offering boys and men opportunities for immersions in caring through school outreaches, volunteer activities, and employment in health care could be meaningful. In addition, mindful of the importance the men placed on support from family and friends, offering the ability to include family and friends when discussing nursing careers and in new student orientation can go far in correcting any misconceptions, dispelling stereotypes, and strengthening social support.
While the aforementioned suggestions may seem, at first blush, to only offer small tweaks, they may have lasting impacts on how men envision themselves as nurses and how they process their experiences in the profession. As mentioned earlier, O'Neil's19 ideas about GRC served as a sensitizing framework for this study, orienting us into the data by drawing attention to both social and individual factors but not necessarily imposing descriptive categorizations of these factors. O'Neil19 proposes GRC as a gender-related context, constructed by multiple macro-societal factors and men's internalization of gender role identity, resulting in psychobehavioral manifestations that are highly individualized and dynamic. The present study constructed a picture of this gender-related context as it pertains to nursing and as it emerged from our interviews with male nursing students.
On the macro-societal level, negative factors described in the study and reported in previous nursing research align with patriarchy-induced distorted gender role schemas.19 For example, beliefs that nursing is gender-inappropriate for men, that men are ill-suited for nursing, or that most male nurses are gay illustrate strong societal messages used by self and others to nudge men into gender role conformity through gender role restriction and devaluation processes. The men were well aware of these messages, which gave some of them pause and apprehension about their decisions. Most men were able to resist and dismiss these messages through affirming and more liberal self-constructions of gender roles influenced by positive factors. Factors such as experiences with men who model caring, honoring personal altruistic attributes, social support, and affirmation for their career decisions, countered negative messages and likely contributed to reduced distortion in personal gender role identities. In contrast, previous studies conducted in Turkey, Iran, Ireland, and China26–29,57 lack the prevalence and strength of positive factors noted in the current study. Men in those studies exhibited clear expressions of gender role restrictions, devaluations, and even violations.
Most importantly, O'Neil19 describes a process of transitions and gender role journey in which men experience psychosocial developmental tasks and interventions to reduce GRC and promote healthy positive masculinity, positive relations with others, and improved quality of life. The model developed in the current study describes the men's generally reflective, intentional, and self-affirming decision-making processes to become nurses in a manner that is congruent with the gender role journey process described by O'Neil.19 These processes occur in community with others and as such are amenable to the intentional introduction of interventional recruitment and retention supports to strengthen the influence of positive factors and facilitate men's entry into nursing practice, thereby reducing gender disparities in the nursing workforce.
LIMITATIONS AND IMPLICATIONS FOR FUTURE RESEARCH
Although the sample was diverse and measures were taken to support qualitative rigor, caution must be taken in transferring the findings broadly to other contexts due to the small sample size and cross-sectional nature of the interviews. Attrition prevented follow-up interviews as the men approached program completion and became nurses. These interviews would have been instrumental in further understanding the proposed decision-making model. On the basis of Larocco's51 model, a hypothesized fourth phase, Living the decision, is presented in the Figure, which would span the time men begin working as nurses until they leave the profession. Previous studies suggest a number of possible positive and negative factors that might impact men's decision to stay in nursing; further research is needed to explore these factors and their variable levels of influence in retention of men in nursing.
The study sample also consisted only of men who progressed through the decision-making processes to the point of enrolling in a formal nursing education program. It is unclear whether the factors presented in the model sufficiently account for those men who decided not to become nurses. Moreover, even if these factors were present in the experiences of men who stopped pursuing nursing, their contextual meanings may have been quite different. Recruitment and retention efforts would benefit from better understanding men's sensemaking when it comes to possibly processing and responding to the same factors in quite different ways. Exploration of the model among men who decided not to become nurses would be of value, particularly as it relates to GRC, although it may prove challenging to locate and access these men.
Although consistent with grounded theory, the current study only used GRC as a sensitizing framework; the results suggest that future research might want to test GRC as an explanatory model for men's decision-making process to become nurses and their experiences as nursing students and professionals. The decision-making model itself presents additional opportunities for research. One possible direction is for future studies to examine the specific manifestations of socialization for men entering and staying in nursing. Jablin58 proposed a particularly relevant model of organizational assimilation that appears to map onto the phases identified in the current study. Jablin's58 model includes (1) anticipatory socialization, which involves making a choice and pursuing better understanding of what an occupation entails; (2) encounter, which consists of observing an organization or an occupation and seeking “membership” in it; and (3) metamorphosis, when people are participating members and seek to resolve incongruencies between their own values and beliefs and those demonstrated in the organization/occupation. Understanding the relative importance factors at each decision-making phase would be helpful in evaluating individual men and targeting specific interventions to support and strengthen their decisions to become nurses.
The qualitative arm of our study explored men's decision-making to become nurses within a larger gendered context. We constructed a decision-making model from data that is largely congruent with findings from previous studies and expands the model proposed by Larocco.51 Importantly, the findings align with GRC and its underlying assumptions. Opposing sets of influencing factors described by our decision-making model are amenable to the development of interventions to mitigate gender disparity in nursing in a manner not unlike O'Neil's19 gender role journey designed to mitigate the negative outcomes of GRC. Although research is needed to further elucidate our decision-making model and explore the manifestations of GRC in nursing, the present study supports the use of GRC as a theoretical framework for research in men in nursing.
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